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Maximizing Synergy Between Federal Health
Information and Technology Programs
Session 203, February 14, 2019
Maria Michaels, Public Health Advisor, Centers for Disease Control and Prevention
Edwin Lomotan, Chief of Clinical Informatics, Agency for Healthcare Research and Quality
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Maria Michaels, MBA, PMP
Has no real or apparent conflicts of interest to report.
The findings and conclusions in this presentation are those of the
authors and do not necessarily represent the official position of the
Centers for Disease Control and Prevention.
Conflict of Interest
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Edwin Lomotan, MD, FAAP, FAMIA
Has no real or apparent conflicts of interest to report.
The findings and conclusions in this presentation are those of the
authors and do not necessarily represent the official position of the
Agency for Healthcare Research and Quality.
Conflict of Interest
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• Review learning objectives and goals for the session
• Describe the overarching challenges for collaboration and how to
choose a problem that can be solved collaboratively
• Illustrate the opportunity for a specific problem that CDC and
AHRQ are helping tackle together by leveraging each other and
shared stakeholder participation
– Overview of CDC’s Adapting Clinical Guidelines for the
Digital Age
– Overview of AHRQ’s Clinical Decision Support initiative
• Describe how you can become involved and make the programs
even better
Agenda
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1. Discuss challenges with operationalizing national health IT
infrastructure across federal agencies and meeting the needs of
many different stakeholder organizations.
2. Identify specific opportunities that led to CDC and AHRQ
collaboration on Adapting Clinical Guidelines for the Digital Age,
CDS Connect, and the Patient-Centered Clinical Decision
Support Learning Network.
3. Outline ways that the stakeholder community and federal
agencies can work more closely together to strategically build
national health IT infrastructure.
Learning Objectives
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The Challenges
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• Complimentary but unique organizational missions
• Program timelines
• Funding sources can offer opportunities but also constraints
• Funding mechanisms and timelines
• Varying levels of evidence to guide programs and demonstration
projects
• Including all appropriate perspectives every time
• Not over-burdening stakeholders who are volunteering their time
to provide guidance and feedback
Overarching Challenges
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• Topic or area that falls under multiple agency missions
• Program timelines align (at least close enough)
• Funding sources do not have constraints that preclude the ability
to use funds to complete the work needed to solve the problem
• Funding mechanisms and timelines align (at least close enough)
• Have sufficient levels of evidence to guide programs at each
respective agency as well as any demonstration projects
• Find ways to “cross pollinate” between agency initiatives that
allows for the appropriate inclusion of stakeholder perspectives
• Do not require inordinate amounts of time from the same
individuals over and over again.
How to Choose a Problem to
Collaboratively Solve
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Eureka! A good problem to solve…
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Today’s Guideline Development and Implementation
Long Implementation Time
Research
Results
Literature
Review
Guideline
Narrative
Develop Guidelines Interpret & Implement Guidelines:
Local Level
Performed by up to 95% of ~5500 hospitals
Interpret & Implement
Guidelines: Across
Health Systems
Performed by up to 82% of ~355,000 clinics
Meta-
analysis
https://dashboard.healthit.gov/quickstats/quickstats.php
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• Guideline authors
• Health IT developers
• Communicators
• Clinicians
• Patients / Patient Advocates
• Medical Societies
• Public Health Organizations
• Evaluation experts
• Standards experts
• Clinical decision support developers
• Clinical quality measure developers
• Policy or technical support for
implementation
Stakeholder Groups Needed to
Help Solve This Problem
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STUDY
ACTPLAN
DO
WANTED:
Complete Feedback Loop
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The Opportunities
For Federal Agency Collaboration
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CDC: Adapting Clinical Guidelines
for the Digital Age
Problem: Long Lag Time,
Inconsistencies, and
Inaccuracies in Translation
Contributes to an average of 17
years for scientific evidence to
apply in patient care
Reason: Playing the
“Telephone Game”
Multiple translations of guidelines
add complexity, opportunity for
error, and variation across
sites/providers
Solution: Developing Tools
and Guidelines Together
Can help evidence apply to
patient care more easily, quickly,
accurately, and consistently
https://www.cdc.gov/ophss/WhatWeDoACG.html
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Redesigning Guideline Development
and Implementation
CURRENT STATE PROPOSED FUTURE STATE
Guidelines
CDS
Patient Care
10s-100s of
translations
100s-1000s of
translations
Guidelines
Informatics
Communications
Implementation
Evaluation
Concurrent
guideline
development
and translation
& upfront
planning
Local Implementation
Patient Care
Inconsistent (or nonexistent)
feedback loop
Consistent feedback
loop
CDS = Clinical Decision Support
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Translating Evidence to Executable CDS
Knowledge
Level
Description Example
L1
Narrative
guideline
Guideline
for a specific disease that is written in the format of a
peer
-reviewed journal article
L2
Semi
-
structured
Flow diagram, decision tree, or other similar format that describes
recommendations for implementation
L3
Structured
Standards
-compliant specification encoding logic with data
model(s), terminology/code sets, value sets that is ready to be
implemented
L4
Executable
CDS
implemented and used in a local execution environment (e.g.,
CDS that is live in an
electronic health record (EHR) production
system
) or available via web services
Adapted from: Boxwala, A. A., et al. (2011). "A multi-layered framework for disseminating knowledge for computer-
based decision support." Journal of the American Medical Informatics Association : JAMIA 18 Suppl 1: i132-139.
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Advancing evidence into practice through CDS and making
CDS more shareable, standards-based, and publicly-available
Four components:
1. Engaging a stakeholder community
2. Creating prototype infrastructure for
sharing CDS and developing CDS
3. Advancing CDS through demonstration
and dissemination research
4. Evaluating the overall initiative
AHRQ: Clinical Decision Support
http://cds.ahrq.gov
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Sharing Clinical Decision Support
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• CDS “Five Rights”
– CDS should deliver the right information, to the right
person, in the right format, in the right channel, at the
right time during work flow.
• CDS as an enabler and tool for quality improvement
– Not just an app, widget, alert, or reminder
– Not just for physicians at the point of care
– Can represent the “actionable” side of quality measurement
Taking a Broad View of CDS
Source: Osheroff JA, Pifer EA, Teich JM, et al. Improving outcomes with clinical decision support: an
implementer's guide. Boca Raton: Productivity Press; 2005.
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CDS Connect: Concept of Operations
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CDS Connect Repository
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Analytic Framework for Action
Blumenfeld, PCCDS LN,
2017
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• AHRQ is an integral part of the CDS community
– Providing a platform for shareable, standards-based, and
publicly-available CDS
– As a convener for standardized approaches to CDS
development and dissemination and patient-centered CDS
• AHRQ helps provide leadership
– Through participation in multiple workgroups of Adapting
Clinical Guidelines for the Digital Age initiative
– Through pilot projects and development of CDS repository
and authoring tools
Collaboration Between AHRQ & CDC
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• CDC is an integral part of the CDS community
– As a guideline developer and disseminator
– As a partner in making CDS more shareable, standards-
based, and publicly-available
– As a convener and source of expertise
• CDC helps provide leadership
– Through the Patient-Centered CDS Learning Network
Steering Committee
– Through the CDS Connect Work Group (Chair)
– Through pilot projects and use of the tools
Collaboration Between AHRQ & CDC
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• Coordinating requests for participation and input across both
agencies’ initiatives
• Incorporating CDS Connect as a platform for dissemination in the
redesigned process for guideline development and
implementation
• Sharing tools, e.g., CDS Authoring Tool
– Leads to broader use and improved development
• Collaborating on specific strategies, e.g., Opioid Action Plan
• Sharing feedback from CDC Request for Information (RFI) on how
to best set up a national testbed for health IT
Successes To Date
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Working Together
Across Federal Agencies and Stakeholder Groups
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• Join CDS Connect Work Group
• Join one (or more!) of the
Adapting Clinical Guidelines for
the Digital Age work groups
– Guideline Creation
– Informatics
– Dissemination and
Communication
– Translation and
Implementation
– Evaluation
• Tell us about use of CDS health IT
standards in the “field”
• Become a pilot partner
• Contribute to the Adapting Clinical
Guidelines for the Digital Age
Implementation Guide
(http://build.fhir.org/ig/cqframework/
cdc-acg/index.html)
• Contribute to the CDS Connect
repository
• Use the open source tools and
contribute feedback
– CDS Authoring Tool
– CQL Services Prototype
– Pain Management Summary
SMART on FHIR App
Opportunities to Make These Programs
Even Better
